THERE'S PROBABLY NOBODY better-qualified than Geoff Alltimes to contribute at the highest levels to the current imbroglios surrounding integration. He cut his early teeth working with Brian Abel-Smith in the then Department of Health and Social Security, with Jack Straw and Lord Norman Warner in different senior roles. Health and social care policy development would have been his bread and butter. “But,” he says, “However much I can do strategy, beneath it all I’m a doer - heavily tactical: I try to persuade people to do things and get things to happen.”And what is he doing now? Currently two days of his week are spent as the senior responsible officer for the NHS in relation to the Pioneer Support Programme. Until March next year he will be leading the so-called barrier-busting team charged, over the five-year period of its term, to making living realities of the integration so many have talked about, for so long, with so little to show for so far.
It is a fairly open secret – and pretty well obvious to all who attended its relaunch earlier this year – that the Programme was not providing the support the pioneers had expected. It was very much the initiative of Care Minister Norman Lamb. Without, it is said, the full-bodied backing from within NHS England the Support Programme stumbled into near-disaster at the end of last year, with developmental inertia slowing down the momentum with which the entire initiative had been launched.
When a fundamental review was undertaken, and a number of changes put in place Geoff was asked to take it on. His recent experiences as the joint chief executive of the Hammersmith and Fulham PCT and Borough Council – an experiment whose ending he still seems to show some regret and disappointment over – put him in a strong position. As did his work on the Prime Minister’s Future Forum, helping successfully to rescue the spirit of integration from Andrew Lansley’s early Coalition reforms.
Remember, Geoff chaired the patient involvement and public accountability workstream in the first phase of the Future Forum. By the time it had entered its second phase it had morphed into the integration workstream and Geoff was chairing that alongside Dr Robert Varnum, a Manchester GP and clinical lead for commissioning at the NHS Institute for Innovation and Improvement: no accident.
When the call came, Geoff said he would take on the role, “because it was a mess, and we needed it to work. But I would only be interested in it if the Pioneer Programme was brought in from the cold, and made part of the bigger integration picture, and not something separate to it. It had been seen as relatively unimportant because only 14 localities are involved. It needed to be, and still needs to be, part of the whole integration picture. That includes the Better Care Fund.”
His only other request before taking up the two-days per week role was that Andrew Webster should make up the other two days: a request that was accepted. Geoff still spends one day per week at the LGA working on the Health Transformation Task Group which he chairs. In its turn that is connected with the Better Care Fund Programme led by Andrew Ridley, with Andrew Webster leading for the LGA.
Futures How have things been with the Pioneers since you took up the post?
Geoff Alltimes We’re working hard. A bottom-up approach has been needed to help those places get on with programme change. It’s long-term: it won’t happen quickly. Pioneers, like everyone else have been caught up in the BCF dramas which came along pretty well at the same time.
Fut And how’s that working out?
GA Pioneers are now much more involved themselves in leading on what we do together. Key workstreams currently being worked on are:
* Informatics/information governance
* Financial modelling, payment systems and the like, closely connected with BCF issues,
* Establishing relationships with providers: how best to do it,
* Leadership and workforce priorities.
Leads were established for each of these streams in the June meeting of the newly inaugurated regular Pioneer Assembly. We are now bringing feedback on each workstream to the next Assembly on November 6. We intend that each of the Streams are brought to a point where we will have something substantial to say then. Meanwhile, by the time of the annual NCASC conference in October Ministers will have announced their decision to expand the Programme by a small number of further pioneers.
Fut Alterations to the BCF formulae and reducing the amount immediately payable upfront to adult social care sent shockwaves through the sector back in the summer. Has this impacted adversely on the Pioneer programme?
GA I prefer to separate the BCF from Pioneers, the one being long term; the other being relatively short term. On the BCF, although places do have these great plans they’re not easily able to work out the full financial modelling necessary for the full business case.
They don’t all have the ready capability to do that. It’s an enormously complicated business to say `we’ll save money on the hospitals by doing it’. It sounds as if it’ll fit with PBR for people in a hospital. But how many people will avoid unnecessary hospital admissions? What is it going to cost to support them at home? What’s going to happen to the beds that are left? Will they simply be filled by other patients being admitted?
The fact of the matter is that the whole system is simply bigger than anything else we’ve ever tried to get to grips with before. Amid an ongoing enormous reorganisation of the NHS.
Fut Given all the battles you’ve won and lost in this struggle for integration, can you see any light ahead? And is it really the end of a tunnel?
GA As you say, I was profoundly disappointed that the joint model in Hammersmith and Fulham was ended by Andrew Lansley’s changes. But I am hopeful. I think we now have a pretty universal recognition that we haven’t been sufficiently patient-centred in the past. That simply has to change, and that move for change is well represented by the centrality of TLAP, National Voices and the `I-statements’. It all obviously connects with Francis in the hospital world – and, as I say, it is a pretty well universally recognised direction of travel.
You talk about the scars... I track those back to the Future Forum. Work on integration wasn’t even on the agenda when I was first asked to be part of its work. The second round did have an integration stream and I co-chaired it. Three or four years ago integration wasn’t on the table: now it’s accepted that it’s part of what’s necessary for improvements in the quality of care for people.
That connects directly with people unnecessarily in hospital. Thirty per cent don’t need to be there and there’s now a clear recognition that if we’re to avoid them being there unnecessarily then we’ve got to develop our community services. There’s a general recognition, too, that we’ve got to do that in terms of joined-up community services that bring social care and community health services closer and closer together. That will have fundamental consequences for bringing staff together from different disciplines as well as in the development of `hybrid’ workers.
We’re now into how to do it on a systemic basis. Some pilots have shown it can be done. But how do you do it for a whole place? The problem with pilots is you press down on one bit of the balloon and it pops up somewhere else. You need to do it in the whole system. The Pioneers are at the forefront of how to do that. These, as well as other fast track localities are showing us the way.
I’m optimistic that the sector and wider public are beginning to understand the issues at stake, but as a member of the Barker Commission report we must eventually get to the Dilnot point… We’ve always said we need reforms in the system and that they’ll cost some money. And we also always said we need additional resources. What Barker says is `yes, we need efficiencies out of integration. But that’s not enough money: there is a huge gap particularly in adult social care.’
Our argument was that they should be the same with a single budget and a single commissioner. You can interpret that in different ways. For me the key point is that when the government makes a decision about NHS funding it should be making a decision in relation to social care funding at the same time. What we had in the last round was Pickles significantly reducing local government funding with Hunt sorting NHS funds. Then a quick fix to say `alright some of the NHS funding has got to be spent jointly, and that’ll bridge the two.'
Alas, what happened was that in the end some of the joint money turned out to be less joint than it appeared, given the way the BCF settlement has worked out. Just think about what the difference would have been if the same amount of money had been there and the system provided £1 billion new money for the NHS to spend jointly with local government, and £1 billion new money was found for local government to spend jointly with the NHS
The difference would have been profound.
Fut But wouldn’t that sort of ring-fencing be complicated for local authorities?
GA Creating the improvements in care that we want with the level of initial funding required will not happen unless politicians and others are confident that that money is going to be identified and spent on what it‘s determined it should be spent on. I think that’s a price we ought to pay in order to be in that territory. Then you get to the point about having a single Commissioner, and the Barker report says we could develop this through Health and Wellbeing Boards. The HWBs are the governance in localities which have councillors, CCGs, Healthwatch as members – and they need to include providers as well. So if we have single commissioning from HWBs we could have:
* CCGs do it on behalf of both local authority and NHS and others.
* Local authorities doing it on behalf of both.
* Or do it by saying some things will be commissioned by one on behalf of both etc, just like we commission for learning disabilities and mental health. Although what we’re talking about is doing it on a scale which is much, much more significant.
I don’t think we want another big, prescribed change, as Barker made clear. We just get into arguments between NHS and local government. We need to achieve on the ground things that only work if people are prepared to work together. All these examples of integration are of people being prepared to look for the win/win of making it work together. That’s what HWBs are about, and I think we can build on it.
What we’re talking about is building a new way of developing, commissioning and delivering services for people who need care. And I think we should think about care, and not separate health and social care. That definitely requires another iteration of how you do that. Local government in the round needs to be a crucial part of that as well as ASC departments.
The unacceptable bit, for me, is that we have a system which is built to make life difficult. Health and social care seem designed to give people grief, having to tolerate one bit of the system fighting against the other. There’s no need for this. If Barker is accepted, the ability to get on with managing a better system; a better quality of life for people in their latter days, and at the end of their lives, will be with us and we could do it.
At present we are confounded by the system, each of us involved in defending the indefensible.
Geoff Alltimes Biography
Geoff Alltimes is the SRO for the integrated care pioneers support programme providing operational support to 14 pioneer sites working to overcome barriers around the integration of health and social care. Geoff also chairs the multi-agency Health Transformation Task Group hosted by the LGA. He was previously chief executive of Hammersmith & Fulham Council, as well as joint chief executive of the PCT. He chaired the NHS Future Forum Patient Involvement and Public Accountability workstream and was joint co-lead on the integration workstream in the second phase Future Forum. He was an associate member of Sir David Nicholson’s NHSCB executive management team meeting. He was a member of the independent Commission on the Future of Health and Social Care chaired by Kate Barker. He is a trustee on the board of Mencap. Geoff was honorary secretary of the Association of Directors of Social Services (ADSS) 1999 – 2002 and in June this year was awarded the Health Service Journal’s number one slot in its Care Integration 50 competition to identify the top 50 integration leads in the country.
ADASS Policy/Press Adviser,
Editor, ADASS Futures